Milverton Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of the legal regulation relating to good governance. This was due to inadequate and ineffective governance systems being in place to identify and respond in a timely manner to safety concerns.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider’s philosophy of care was clearly displayed and accessible for all to see and read. This philosophy and the provider’s values were incorporated throughout the system and informed the recruitment process and were discussed during supervision sessions to ensure staff continued to adhere to and display these principles.

The provider had inclusive leaders at all levels who understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation. However, they did always make themselves accessible and approachable to all.

A registered manager was in post. They had undertaken additional courses in management and leadership in health and social care, and from this had joined a group of managers for support and to share learning. A management and leadership structure was in place. This gave staff clear information about who to go to for guidance and support. Staff told us they felt well supported. One staff member said, “[The registered manager] is wonderful. She is very supportive.”

We received mixed feedback from people and relatives about the management and leadership of the service. A relative said, “[The registered manager] and [clinical leader] are who I would go to if there has been a problem. Yes, they are approachable.” Another relative told us, “[The clinical lead] is the last of the long-term staff remaining here – I would go to her if there was a problem. I would not feel comfortable speaking about how I really feel about things to anyone else.” Some people we spoke with were guarded and felt unable to speak openly.

The registered manager was aware of their CQC registration responsibilities and submitted statutory notifications about key events that occurred at the service as required.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt able to speak up and approach their manager if they had any concerns. The registered manager told us they encouraged staff to express their views and share their opinions. A whistleblowing policy was in place which was accessible to all staff. The complaints procedure was clearly displayed and encouraged people and relatives to speak up if they had any concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Equality and diversity policies and procedures were in place, this supported staff from all backgrounds to ensure they were protected from discrimination. Policies were in place to support expectant mothers and those who were experiencing stress at work.

The registered manager was supportive and flexible to accommodate staff’s individual requests. Rotas took account of religious festivals and supported staff who were celebrating to have leave where possible. The registered manager told us, “Staff work really well together and support each other with swapping shifts. I always encourage holiday and annual leave.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A governance system was in place which included audits of medicines management, infection prevention and control processes as well as other key areas. There were also systems in place to track and monitor compliance with staff training and supervision. However, some of these systems had not been kept up to date or they had been amended and there had been a delay in starting the new system. For example, supervision sessions had been restructured and, whilst supervision sessions were starting to be completed again, there had been a slight slip in compliance. The environmental risk assessments and other environmental checks had not identified the concern with window restrictors, and the medicines audits had not been proactive in identifying the extent of the concerns we found. There was not a comprehensive care record audit in place at the time of our assessment. This was a breach of the legal regulation relating to good governance.

Governance meetings were held with senior staff. The last meeting was held the week before our assessment. Staff had identified some concerns with the medicines management systems relating to ordering of medicines and had already arranged for the pharmacy to visit and undertake their own audit later in the month. The registered manager informed us since our site visit, they had implemented a care records audit and they would ensure regular audits were undertaken to ensure the completeness of care records.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Relatives did not always feel like the home worked in partnership with them. Some relatives felt communication could be improved to ensure open and effective messages were relayed. A relative told us, “The communication has not been good regarding the changes in care staff.” Another relative said, “You can ask to have a meeting with the nurses – I’m not sure about general meetings.”

Satisfaction surveys were sent out to relatives and we saw the responses were mainly positive. However, the findings from surveys had not been analysed so we could not be assured how these were being used to effectively inform service development.

The home worked in partnership with the local authority quality assurance team. They welcomed visits by the team to review the safety and quality of service provision and worked with them to incorporate improvements at the service. However, the last visit in December 2024 had identified concerns with the quality and completeness of care records, and we continued to have concerns in this area.

The home also worked in partnership with their local Healthwatch, and a recent enter and view visit had been completed. The management team took on board the recommendations from Healthwatch and had already implemented several of them. They were looking into how to provide a more dementia friendly environment in line with the recommendations made.

The provider was committed to continuous learning, innovation and improvement across the organisation and local system. However, our findings at this assessment indicated that the provider had not been proactive in identifying and addressing their own learning and improvement. They did not have a service improvement plan in place at the time of our site visit to drive continuous improvement.

The registered manager was open to our feedback and had a desire to improve practices at the service. After our site visit, they undertook their own internal audits, specifically of care records and medicines management arrangements. They provided us with details of the actions they planned to undertake to address the concerns identified and ensure ongoing monitoring and governance of these processes.

The staff had acted on our previous assessment of the service and had addressed areas requiring improvement in relation to DBS checks, duty of candour and ensuring a registered manager was in post.

The home had implemented a few initiatives and projects since our last inspection, namely the safeguarding toolkit and hydration toolkit. They had plans to take part in additional pilots and projects, including the use of facial recognition tool to assess pain levels. We will review the impact of this at our next assessment.